=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164287066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DM LASER AND DERMA CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2024
-----------------------------------------------------
Last Update Date | 02/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 W COLLEGE ST FL 3
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-915-1911
-----------------------------------------------------
Fax | 626-915-2668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 W COLLEGE ST FL 3
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-915-1911
-----------------------------------------------------
Fax | 626-915-2668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. HENRICK MACALINTAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-863-3433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------